Perioperative fluid management and outcomes in adult deceased donor liver transplantation - A systematic review of the literature and expert panel recommendations

Optimization and Protection of Kidney Health in Liver Transplant Recipients: Intra- and Postoperative Approaches

Postoperative acute kidney injury after liver transplant (LT) has long-term implications for kidney health. LT recipients are at risk of acute kidney injury due to a number of factors related to the donor liver, intraoperative factors including surgical technique, as well as recipient factors, such as pre-LT kidney function and postoperative complications. This review discusses these factors in detail and their impact on posttransplant kidney function. Long-term risk factors such as calcineurin inhibitors have also been discussed. Additionally, the impact of liver allocation policies on pre- and post-LT kidney health is discussed.

Postoperative fluid balance and outcomes in pediatric living-donor liver transplant recipients: a retrospective cohort study

PURPOSE

This study aimed to investigate the relationship between postoperative fluid balance (FB) and clinical outcomes in pediatric living-donor liver transplant (LDLT) recipients.

METHODS

This retrospective study was conducted at a tertiary care center. Patients aged ≤ 18 years who underwent LDLT between January 2010 and September 2023 were included. Postoperative FB was calculated as [(total fluid intake-total fluid output) / body weight] × 100 for 48 h. Patients were categorized into four groups: < 5%, 5-10%, 10-15%, and ≥ 15% FB. The primary outcome was ventilator-free days (VFD) within 30 days post-transplantation. Secondary outcomes included acute kidney injury (AKI), reintubation, hepatic arterial thrombosis, acute rejection, primary graft dysfunction, intensive care unit (ICU) length of stay (LOS), and mortality.

RESULTS

The study included 200 patients with a median weight of 9.0 (interquartile range [IQR]: 6.9-19.3) kg. Median VFD did not significantly differ across the FB groups: < 5% FB, 29.3 (IQR, 28.3-29.4) days; 5-10% FB, 29.3 (IQR, 28.3-29.4) days; 10-15% FB, 29.3 (IQR, 28.3-29.4) days; and ≥ 15% FB, 27.4 (IQR, 23.3-29.4) days (p = 0.27). However, multivariable analysis showed ≥ 15% FB was associated with 4.59 days shorter VFD (p = 0.004) and higher AKI incidence (odds ratio: 6.60, p = 0.012). Thrombosis occurred in 7 patients (3.5%) with no significant differences among groups (p = 0.61). Other secondary outcomes showed no significant differences.

CONCLUSION

Excessive postoperative FB (≥ 15%) in pediatric LDLT recipients was significantly associated with reduced VFD and increased AKI incidence, whereas other adverse outcomes were not significantly affected.

EASL Clinical Practice Guidelines on extrahepatic abdominal surgery in patients with cirrhosis and advanced chronic liver disease

Extrahepatic surgery in patients with cirrhosis of the liver represents a growing clinical challenge due to the increasing prevalence of chronic liver disease and improved long-term survival of these patients. The presence of cirrhosis significantly increases the risk of perioperative morbidity and mortality following abdominal surgery. Advances in preoperative risk stratification, surgical techniques, and perioperative care have led to better outcomes, yet integration of these improvements into routine clinical practice is needed. These clinical practice guidelines provide comprehensive recommendations for the assessment and perioperative management of patients with cirrhosis undergoing extrahepatic surgery. An individualised patient-centred risk assessment by a multidisciplinary team including hepatologists, surgeons, anaesthesiologists, and other support teams is essential.

Fluid balance dynamics and early postoperative outcomes in orthotopic liver transplantation: a prospective cohort study

INTRODUCTION

This study evaluates the impact of Fluid Balance (FB) patterns on outcomes after Orthotopic Liver Transplantation (OLT). It hypothesizes that deviations from optimal FB increase morbidity.

METHODS

In a single-center cohort post hoc analysis of 73 post-OLT patients, FB was categorized into three groups based on cumulative FB at 72 hours: Lowest (negative FB), Intermediate (0-2000 mL), and Highest (> 2000 mL). We analyzed Sequential Organ Failure Assessment (SOFA) scores, mortality rates, and causes of death. Logistic regression identified mortality predictors.

RESULTS

The Highest FB group had the highest SOFA scores and mortality (Group "Lo": 18.2%, Group "In": 8.6%, Group "Hi": 40.5%, p = 0.009). A U-shaped relationship between FB and hospital mortality was observed, with extremes of FB associated with higher mortality. Cumulative FB independently predicted all-cause mortality with a 29.5% increase in the risk of death. FB on day 3 also predicted all-cause mortality, increasing the risk by 83.9%. Furthermore, FB on day 1 was linked to a 134.5% increase in the risk of death due to primary non-function of the liver. SOFALIVER score strongly predicted all-cause mortality, with a one-point increase associated with a 98.8% to 114.7% increase in mortality risk.

DISCUSSION

These findings suggest that both negative and positive extremes of FB are associated with worse outcomes after OLT, reinforcing the U-shaped relationship between FB and mortality. Our results underscore the importance of balanced fluid management, particularly in the early postoperative period. The study highlights the need for individualized FB strategies to optimize organ function and reduce mortality. The use of SOFALIVER scores as a predictor of mortality further emphasizes the importance of liver function monitoring in post-OLT patients. However, the single-centre design and convenience sample limit the generalizability of our findings, necessitating validation through multicenter studies.

CONCLUSION

Our study provides valuable insights into the relationship between FB patterns and mortality in OLT patients. Both negative and positive extremes of FB are associated with higher mortality, suggesting the need for a balanced and individualized fluid management approach. The strong predictive value of SOFALIVER scores for all-cause mortality highlights the importance of early and continuous monitoring of liver function. Future multicenter randomized controlled trials are needed to validate these findings and develop optimized fluid management protocols for OLT patients.

Perioperative administration of albumin in adult patients undergoing liver transplantation: A systematic review

Hypoalbuminemia is a risk factor for mortality in patients with end-stage liver disease (ESLD) and in those undergoing orthotopic liver transplantation (OLT), since it represents a biomarker of post-operative delayed functional recovery of the graft. Despite albumin infusion during and after OLT is frequently adopted in recipients with hypoalbuminemia, it remains unclear whether this procedure could improve post OLT clinical outcomes. Observational studies indicated that treatment with albumin after OLT might be beneficial in reducing ascites and acute kidney injury (AKI) development. However, considering potential complications and the cost of albumin therapy, the decision to use albumin after OLT should be based on careful consideration of patient's individual needs and risks. In addition, the threshold plasma value of albumin below which it could be clinically useful to infuse albumin has not been clearly defined. This systematic review, prepared in accordance with the PRISMA 2020 guidelines, aimed to assess the efficacy of albumin infusion in patients undergoing OLT, in the prevention or treatment of ascites, AKI, and ischemia reperfusion syndrome, as well as its potential impact on patient survival. Furthermore, this review aimed to illustrate the pathophysiological bases justifying the use of albumin infusion in a subset of patients receiving OLT.

Evaluation of Postoperative Acid-Base Balance and Lactate Levels as Predictors of ICU Length of Stay in Liver Transplant Patients

PURPOSE

Liver transplantation is a life-saving procedure for patients with end-stage liver disease. The postoperative period presents significant challenges, particularly in managing acid-base balance and lactate levels, which are crucial indicators of metabolic stability and tissue perfusion. While these parameters provide valuable insights into patient recovery, their role in predicting intensive care unit (ICU) length of stay remains unclear. This study evaluates whether early postoperative acid-base balance and lactate levels can reliably predict ICU length of stay in liver transplant recipients, aiming to enhance postoperative care strategies.

METHODS

A retrospective observational study was conducted on 53 adult liver transplant recipients. Acid-base and lactate parameters were measured at two-time points: early (within the first 6 hours) and late (6-24 hours) postoperatively. Paired t-tests and Wilcoxon signed-rank tests were used to compare these measurements. Multiple linear regression modeling was employed to assess the impact of these parameters on ICU length of stay.

RESULTS

Significant changes were observed in FiO2, pH, Base Excess, HCO3, lactate, and Strong Ion Difference (SID) between early and late postoperative measurements (P < .05). However, regression analysis revealed that maximum lactate and early SID were not strong predictors of ICU length of stay (R² = 0.062). Exploratory analyses indicated that patients with elevated SID and markedly high lactate levels tended to have prolonged ICU stays.

CONCLUSIONS

While postoperative acid-base balance and lactate levels are important indicators of physiological status in liver transplant recipients, they do not serve as strong independent predictors of ICU length of stay.

The Effect of Perioperative Fluid Therapy on Postoperative Renal Functions in Patients Receiving Liver Transplantation from Living Donors: A Retrospective Observational Study

Background

Perioperative fluid management (PFM) is critical in liver transplantation, especially regarding its impact on postoperative renal function. Acute kidney injury (AKI) is a common complication in liver transplant recipients, often influenced by the type and volume of fluids administered during the perioperative period. This study investigates the effects of different fluid management strategies on renal outcomes following liver transplantation from living donors.

Patients and methods

This retrospective observational study included 91 liver transplant recipients who were categorized into three groups based on their PFM strategy: restrictive (n = 1), moderate (n = 34), and liberal (n = 56). Data were collected from patient medical records, focusing on fluid types, peak serum creatinine levels, urine output, and length of hospital stay. Statistical analyses, including ANOVA and logistic regression, were conducted to assess renal outcomes among the groups.

Results

The moderate fluid management group demonstrated the best renal outcomes, with the lowest peak serum creatinine (1.02 ± 0.25 mg/dL) and shorter ICU stays (2.47 ± 0.62 days) compared to the liberal fluid strategy group (1.40 ± 0.92 mg/dL and 2.88 ± 0.83 days, respectively). Moreover, liberal fluid strategies were associated with fluid overload and increased peak serum creatinine levels. Intraoperative fluid administration showed a greater protective effect on renal function compared to postoperative fluid administration.

Conclusions

Moderate PFM, particularly with careful intraoperative fluid administration, is optimal for minimizing the risk of AKI and improving renal outcomes in liver transplant patients. These findings emphasize the importance of individualized fluid therapy in reducing renal complications after liver transplantation.

How to cite this article

Kızılcık N. The Effect of Perioperative Fluid Therapy on Postoperative Renal Functions in Patients Receiving Liver Transplantation from Living Donors: A Retrospective Observational Study. Indian J Crit Care Med 2025;29(3):251-261.

Relevance of perioperative fluid dynamics in liver transplantation to acute kidney injury and patient outcomes: a cross-sectional survey

Background

Fluid administration is a critical component of perioperative management for liver transplant recipients, and excessive fluid infusion can lead to acute kidney injury (AKI) and poor patient outcomes.

Method

We conducted a cross-sectional survey on the fluid intake and output of adult liver transplant recipients over a 7-day period. The patients were divided into AKI and non-AKI groups. Multivariate logistic regression analyses were used to evaluate the association between fluid balance (FB) and AKI. A Kaplan-Meier survival analysis was performed to determine the survival of the recipient survival at 180 days.

Results

A total of 210 liver transplant recipients were included. The peak FB occurred on the second day after transplantation, which was higher than on the seventh day (0.3 [IQR, -0.2 to 0.8] L vs. -0.4 [IQR, -1.0 to 0.3] L, p < 0.001). The highest incidence of AKI was observed on the second day after transplantation and the lowest on the seventh day (52.4% vs. 15.4%, p < 0.001). Multivariate analysis showed that a cumulative FB > 1 L within the first 2 days postoperatively was an independent risk factor for AKI on the second day after liver transplantation (LT) (OR = 2.66, 95% CI, 1.31-5.41, p = 0.007). Survival analysis indicated significant differences in 180-day survival rates among patients with different grades of AKI [94.0% (grade 1) vs. 91.4% (grade 2) vs. 77.8% (grade 3), χ 2  = 12.93, p < 0.001].

Conclusion

There is a significant correlation between post-LT AKI and perioperative FB. Cumulative FB > 1 L in the first 2 days postoperatively is an independent risk factor for AKI on the second day after LT. AKI after LT is associated with a lower 180-day survival rate in patients.

Anesthesia management of CRS and HIPEC in advanced ovarian cancer with ultra-high intra-abdominal pressure: a case report

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a leading treatment for advanced ovarian cancer, significantly improving overall survival and disease-free survival. This case involves a patient with peritoneal metastasis and ultra-high intra-abdominal pressure (36 mmHg). CRS + HIPEC induces extensive pathological and physiological changes affecting respiratory, circulatory, renal, coagulation, and metabolic systems. Effective perioperative anesthesia management, including the type and volume of fluids administered, is crucial for optimizing patient outcomes. The complexities of anesthesia management in such cases present significant challenges.

Anesthesia for Combined Heart-Liver Transplantation: A Narrative Review

In 1984, 21 years after the first liver transplantation, Thomas Starzl achieved a milestone by performing the world's first combined heart-liver transplantation. While still uncommon, the practice of combined heart-liver transplants is on the rise globally. In this review, the authors delve into the current literature on this procedure, highlighting the evolving landscape and key considerations for anesthesiologists. Over the years, there has been a remarkable increase in the number of combined heart-liver transplantations conducted worldwide. This surge is largely attributed to the growing population of adult survivors with single-ventricle physiology, palliated with a Fontan procedure, who later present with late Fontan failure and Fontan-associated liver disease. Research indicates that combined heart-liver transplantation is an effective treatment option, with reported outcomes comparable with isolated heart or liver transplants. Managing anesthesia during a combined heart-liver transplant procedure is challenging, especially in the context of underlying Fontan physiology. International experience in this field remains somewhat limited, with most techniques derived from expert opinions or experiences with single-organ heart and liver transplants. These procedures are highly complex and performed infrequently. As the number of combined heart-liver transplants continues to rise globally, there is a growing need for clear guidance on periprocedural surgical and anesthetic management. Anesthesiologists overseeing these patients must consider multiple factors, balancing various comorbidities with significant hemodynamic and metabolic shifts. An increase in (multicenter) studies focusing on specific interventions to enhance patient and organ outcomes is anticipated in the coming years.

Bridging the critically ill patient with acute to chronic liver failure to liver transplantation

Liver transplantation (LT) has emerged as an effective therapy for severe forms of acute-on-chronic liver failure (ACLF), an entity characterized by the development of multiorgan failure and high short-term mortality. The aim of critical care management of ACLF patients is to rapidly treat precipitating events and aggressively support failing organs to ensure that patients may successfully undergo LT or, less frequently, recover. Malnutrition and sarcopenia are frequently present, adversely impacting the prognosis of these patients. Management of critical care patients with ACLF is complex and requires the participation of different specialties. Once the patient is stabilized, a rapid evaluation for salvage LT should be performed because the time window for LT is often narrow. The development of sepsis and prolonged organ support may preclude LT or diminish its chances of success. The current review describes strategies to bridge severe ACLF patients to LT, highlights the minimal evaluation required for listing and the currently suggested contraindications to proceed with LT, and addresses different aspects of management during the perioperative and early posttransplant period.

Impact of Albumin Infusion Compared With Crystalloid Infusion on Organ Function After Liver Transplantation in Adult Patients

OBJECTIVES

To compare the clinical benefit of using albumin versus crystalloids for volume resuscitation on organ function in adult patients after liver transplantation.

DESIGN

A retrospective cohort study SETTING: Data from a tertiary care facility electronic medical records on liver transplantation patients admitted to the intensive care unit (ICU).

PATIENTS

Adults admitted to the ICU after liver transplantation.

INTERVENTIONS

Crystalloid fluid resuscitation compared to albumin 5% in the immediate postoperative period after liver transplant.

MEASUREMENTS AND MAIN RESULTS

Adults who underwent liver transplant surgery and received a 5% albumin solution were compared with those who received a crystalloid solution. Demographic, etiology, clinical variables, perioperative, and outcome variables were collected. The data were analyzed using the t test, two-way analysis of variance, and multivariate analysis. After applying all the exclusion criteria, the study group comprised 57 adult patients (30 males; 52.6%) who underwent liver transplantation, including 27 patients in the crystalloid group (47.4%) and 30 patients in the albumin group (52.6%). The mean patient age was 52.2 years. Patient characteristics were similar in the 2 groups. Daily Sequential Organ Failure Assessment (SOFA) scores decreased gradually during the postoperative period in both groups, and the trend in SOFA scores was similar in the 2 groups. Analysis showed no statistical difference in SOFA score between the 2 groups postoperatively (P = .84). Multivariate linear regression analysis identified the Model for End-stage Liver Disease (MELD) score as a predictor of the 7-day postoperative SOFA score in this population.

CONCLUSIONS

In this study, the use of albumin or crystalloid solution in patients undergoing liver transplantation appeared to have no significant difference in terms of the risk of organ dysfunction. However, further research is needed to confirm these findings and fully understand the potential benefits and risks of using either type of fluid.

Chinese Society of Cardiology guidelines on the diagnosis and treatment of adult fulminant myocarditis

Fulminant myocarditis is an acute diffuse inflammatory disease of myocardium. It is characterized by acute onset, rapid progress and high risk of death. Its pathogenesis involves excessive immune activation of the innate immune system and formation of inflammatory storm. According to China's practical experience, the adoption of the "life support-based comprehensive treatment regimen" (with mechanical circulation support and immunomodulation therapy as the core) can significantly improve the survival rate and long-term prognosis. Special emphasis is placed on very early identification,very early diagnosis,very early prediction and very early treatment.

Consensus document from the Spanish Society for Liver Transplantation: Enhanced recovery after liver transplantation

The goal of the Spanish Society for Liver Transplantation (Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, in November 2022, the 10th Consensus Document Meeting was held, with the participation of experts from the 26 authorized Spanish liver transplantation programs. This edition discusses enhanced recovery after liver transplantation, dividing needed actions into 3periods: preoperative, intraoperative and postoperative. The evaluated evidence and the consensus conclusions for each of these topics are described.

Consensus document from the Spanish Society for Liver Transplantation: enhanced recovery after liver transplantation

The goal of the Spanish Society for Liver Transplantation (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, in November 2022, the 10th Consensus Document Meeting was held, with the participation of experts from the 26 authorized Spanish liver transplantation programs. This edition discusses Enhanced Recovery After Liver Transplantation, dividing needed actions into three periods: preoperative, intraoperative and postoperative. The evaluated evidence and the consensus conclusions for each of these topics are described.

Enhanced recovery after surgery for liver transplantation: a review of recent literature

PURPOSE OF REVIEW

This review was created to highlight important articles from the past year related to the evolving field of enhanced recovery after surgery (ERAS) in liver transplantation that are relevant to the transplant anesthesiologist.

RECENT FINDINGS

The International Liver Transplantation Society (ILTS) recently completed a landmark project, the ERAS4OLT.org project, which culminated in 80 recommendations for ERAS in liver transplantation. These recommendations encompass management for deceased donor recipients, living donor recipients and living donors. This review highlights selected articles relevant to the perioperative management of deceased donor liver transplant recipients.

SUMMARY

Though, there are now published internationally agreed upon recommendations for ERAS topics specific to liver transplantation, there is an obvious need for further investigation into this area to provide high quality evidence to support these recommendations. It is reasonable to utilize these recommendations in ERAS protocols for individual institutions; however, more evidence is needed in several areas to confirm the effects of these protocols on short-term outcomes.

An overview of unresolved issues in the perioperative management of liver transplant patients

Over the past decade, the field of solid organ transplantation has undergone significant changes, with some of the most notable advancements occurring in liver transplantation. Recent years have seen substantial progress in preoperative patient optimization protocols, anesthesia monitoring, coagulation management, and fluid management, among other areas. These improvements have led to excellent perioperative outcomes for all surgical patients, including those undergoing liver transplantation. In the last few decades, there have been numerous publications in the field of liver transplantation, but controversies related to perioperative management of liver transplant recipients persist. In this review article, we address the unresolved issues surrounding the anesthetic management of patients scheduled for liver transplantation.

Anesthesia and Critical Care for the Prediction and Prevention for Small-for-size Syndrome: Guidelines from the ILTS-iLDLT-LTSI Consensus Conference

BACKGROUND

During the perioperative period of living donor liver transplantation, anesthesiologists and intensivists may encounter patients in receipt of small grafts that puts them at risk of developing small for size syndrome (SFSS).

METHODS

A scientific committee (106 members from 21 countries) performed an extensive literature review on aspects of SFSS with proposed recommendations. Recommendations underwent a blinded review by an independent expert panel and discussion/voting on the recommendations occurred at a consensus conference organized by the International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplantation Society of India.

RESULTS

It was determined that centers with experience in living donor liver transplantation should utilize potential small for size grafts. Higher risk recipients with sarcopenia, cardiopulmonary, and renal dysfunction should receive small for size grafts with caution. In the intraoperative phase, a restrictive fluid strategy should be considered along with routine use of cardiac output monitoring, as well as use of pharmacologic portal flow modulation when appropriate. Postoperatively, these patients can be considered for enhanced recovery and should receive proactive monitoring for SFSS, nutrition optimization, infection prevention, and consideration for early renal replacement therapy for avoidance of graft congestion.

CONCLUSIONS

Our recommendations provide a framework for the optimal anesthetic and critical care management in the perioperative period for patients with grafts that put them at risk of developing SFSS. There is a significant limitation in the level of evidence for most recommendations. This statement aims to provide guidance for future research in the perioperative management of SFSS.

Prognostic Factors for Postoperative Bleeding Complications and Prolonged Intensive Care after Percutaneous Hepatic Chemosaturation Procedures with Melphalan

Percutaneous hepatic melphalan perfusion (chemosaturation) in patients with liver metastases is known to be associated with procedure-related hemodynamic depression and coagulation impairment, which may cause bleeding complications and/or a prolonged intensive care unit length of stay (ICU LOS). We retrospectively analyzed possible predictive factors for bleeding complications and an ICU LOS > 1 d in a cohort of 31 patients undergoing 90 chemosaturation procedures. Using a multivariable mixed-model approach, we identified the amount of perioperative fluid volume (OR 12.0, 95% CI 2.3-60.0, p = 0.003) and protamine (OR 0.065, 95% CI 0.007-0.55, p = 0.012) to be associated with bleeding complications. Furthermore, the amount of perioperative fluid volume was associated with an ICU LOS > 1 d (OR 5.2, 95% CI 1.4-19.0, p = 0.011). Heparin dosage, melphalan dosage, extracorporeal circulation time, and noradrenaline dosage had no significant effects on outcomes. Protamine use was not associated with anaphylactic or thromboembolic complications. Despite the limited sample size, these results suggest a restrictive perioperative fluid regime to be beneficial, and support the use of protamine for heparin reversal after chemosaturation procedures. Further prospective randomized trials are needed to confirm these findings.

Characteristics, Risk Factors, and Outcome of New-onset Systolic Heart Failure After Liver Transplantation: A Single-center Cohort

New-onset systolic heart failure (HF) after liver transplantation (LT) is a significant cause of morbidity and mortality; however, its characteristics are still insufficiently delineated. HF may involve the left ventricle (LV), right ventricle (RV), or both ventricles. We explored the incidence, characteristics, etiologies, risks, involved cardiac chambers, and outcomes of HF after LT.

Methods

This study included 528 adult patients with preoperative LV ejection fraction ≥ 55% who underwent LT between 2016 and 2020. The primary outcome was new-onset systolic HF, defined by the presence of clinical signs, symptoms, and echocardiographic evidence of reduced LVejection fraction <50% and RV dysfunction within the first year after LT.

Results

Thirty-one patients (6%) developed systolic HF within a median of 9 d (1-364). Of those, 23% of patients had ischemic HF, whereas 77% had nonischemic HF. Nonischemic HF was caused by stress (11), sepsis (8), or other factors (5). Nonischemic HF was secondary to isolated LV failure in 58% of patients or RV ± LV failure in 42% of patients. Recursive partitioning identified subgroups with varying risks and uncovered interaction between variables. HF risk increased from 4.2% to 13% when epinephrine and/or norepinephrine drips were used intraoperatively (P < 0.01). When no epinephrine and/or norepinephrine were used, HF risk increased from 3.1% to 38.5% if baseline hemoglobin was <7.2 g/dL (P < 0.01). When baseline hemoglobin was ≥7.2 g/dL, HF risk increased from 0% to 5.2% when ≥3500 mL crystalloid was used intraoperatively (P < 0.01). Posttransplant first-year survival and reversibility of HF depended on the etiology (stress, sepsis, ischemia, etc) and cardiac chamber involvement (isolated LV or RV ± LV). RV dysfunction was associated with inferior recovery of cardiac function and poorer survival than nonischemic isolated LV dysfunction (50% versus 70%, respectively).

Conclusions

Posttransplant new-onset HF is mostly nonischemic in nature and is associated with increased morbidity and mortality.

Issues in multi-organ transplantation of the liver with kidney or heart in polycystic liver-kidney disease or congenital heart disease: Current practices and immunological aspects

Solid organ transplantation has become an integral part of the management of patients with end-stage diseases of the kidney, liver, heart and lungs. Most procedures occur in isolation, but multi-organ transplantation of the liver with either the kidney or heart has become an option. As more patients with congenital heart disease and cardiac cirrhosis survive into adulthood, particularly after the Fontan procedure, liver transplant teams are expected to face questions regarding multi-organ (heart-liver) transplantation. Similarly, patients with polycystic kidneys and livers may be managed by multi-organ transplantation. Herein, we review the indications and outcomes of simultaneous liver-kidney transplantation for polycystic liver-kidney disease, and discuss the indications, timing and procedural aspects of combined heart-liver transplantation. We also summarise the evidence for, and potential mechanisms underlying, the immunoprotective impact of liver allografts on the simultaneously transplanted organs.

Enhanced recovery for liver transplantation: recommendations from the 2022 International Liver Transplantation Society consensus conference

There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelines on enhanced recovery for liver-transplant recipients. The ERAS4OLT.org collaborative partnered by the International Liver Transplantation Society performed systematic literature reviews on the effect of 32 relevant enhanced perioperative recovery elements on short-term outcomes, and global specialists prepared expert statements on deceased and living donor liver transplantation. The Grading Recommendations, Assessment, Development and Evaluations approach was used for rating of quality of evidence and grading of recommendations. A virtual international consensus conference was held in January, 2022, in which results were presented, voted on by the audience, and discussed by an independent international jury of eight members, applying the Danish model of consensus. 273 liver transplantation specialists from 30 countries prepared expert statements on elements of enhanced recovery for liver transplantation based on the systematic literature reviews. The consensus conference yielded 80 final recommendations, covering aspects of enhanced recovery for preoperative assessment and optimisation, intraoperative surgical and anaesthetic conduct, and postoperative management for the recipients of liver transplants from both deceased and living donors, and for the living donor. The recommendations represent a comprehensive overview of the relevant elements and areas of enhanced recovery for liver transplantation. These internationally established guidelines could direct the development of enhanced recovery programmes worldwide, allowing adjustments according to local resources and practices.